The G.O.P. Accidentally Replaced Obamacare Without Repealing It

President Trump signing an executive order in October to make it easier for Americans to buy bare-bones health insurance plans and circumvent Obamacare.CreditCreditKevin Lamarque/Reuters

Congressional Republicans spent the better part of 2017 trying and failing to repeal and replace Obamacare. They have now largely abandoned the project to pursue other goals. Yet in a sense they have succeeded anyway — just not in the manner they expected.

Consider for a moment what a successor to the Affordable Care Act might have looked like if Republicans had somehow managed to both repeal and replace the law last year.

Although the hastily written replacement bills that made their way through Congress were often vague and uneven, they tended to push the law in predictable directions: more federalism and individual choice, fewer mandates and more state flexibility, cheaper plans with less comprehensive coverage. They aimed to reduce some subsidies associated with the law while also, in some cases, providing funds to help states shore up Obamacare’s unstable marketplaces. They pared back the law’s Medicaid expansion and consistently took aim at its individual mandate.

None of those plans or quasi-plans passed. But roughly speaking, this is the form that the Affordable Care Act is now starting to take, thanks to a series of changes that Republicans have ushered into place since the failure of repeal.

Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it.

The changes are happening at both the state and federal levels. Wisconsin’s Republican governor, Scott Walker, a staunch Obamacare opponent, recently signed a bill giving the state access to $150 million in federal funds to bolster its health insurance exchange.

Republicans in Congress are also debating measures to prop up the exchanges, and the White House has signaled support — so long as some additional changes are made that would move the law in a more conservative direction.

Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).

The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so.

At the same time, the health department is setting limits on how far states can go with their experiments: Idaho recently proposed a scheme to allow insurers to sell plans that do not comply with all of Obamacare’s regulations, with the goal of creating a market for less expensive, less robust coverage, but last week the department rejected the plan as illegal (Gov. Butch Otter didn’t see it as a rejection but as an invitation to “continue discussing the specifics”). And while the Trump administration approved a request to add work requirements to Medicaid in Arkansas, it has held off on approving a rollback in enrollment.

There are practical virtues in some of these initiatives: Efforts to expand the availability of cheaper, less regulated plans, for example, can provide alternatives to Obamacare’s ever-rising premiums. But there are risks as well. Thanks to the way the health law’s subsidies are structured, Mr. Trump’s decision to cut off subsidy payments is likely to increase overall federal spending. The design of the cost-control board was legally questionable, but it represented an effort to cap the growth of America’s largest entitlement program, and Republicans replaced it with nothing.

And at times, the tweaks and fixes seem to be at war with one another. Those same short-term plans are likely to pull healthy people out of the exchanges, further destabilizing the markets and creating pressure to prop them up with subsidies and stabilization funds, which cost the government money.

Supporters of the health care law might describe many of these changes as sabotage, and it’s certainly true that many of them are not being made out of love for the law. But the changes also suggest that Republicans are belatedly engaging with the particulars of the law and its operation, cobbling together a not entirely coherent replacement on the fly.

Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.

To be sure, the embrace is not without reservation. A group of conservative states recently unleashed another legal challenge to the law. Senator Orrin Hatch of Utah recently called it the “stupidest dumbass bill that I’ve ever seen.” But in arranged marriages, love often grows over time.

The end result of this process is likely to be a system that offers cheaper insurance for many but is more fractured, more frustrating and perhaps more expensive for taxpayers — more of a safety net than a support system.

It is also likely that Democrats will respond in kind. They are already regrouping around efforts to move closer to a single-payer system: in the full-throated support for single-payer health care now offered by prominent liberal politicians who aren’t named Bernie Sanders; in the push for state-based single-payer health care; and in the embrace of not-quite-single-payer systems by influential left-leaning policy shops like the Center for American Progress.

In some ways, this future, should it come about, would represent a tectonic shift in the political dynamic surrounding American health care policy, a twist in which the party that gave us Obamacare moves on while the party that opposed it takes over its defense.

But in another way, it would merely offer a reset, a return to the more natural dynamic that largely defined the right-left divide on health care policy in the years before Obamacare, in which Republicans like Mitt Romney defended, or at least tolerated, some combination of regulated private insurance and the employer-coverage status quo while Democrats pushed for ever greater government provision of care.

In the short term, at least, this turn may well benefit the Republican Party. Indeed, Obamacare is now more popular than ever. But it’s a dynamic that deprives the nation of a real debate about how health care should be financed, regulated and provisioned, because it assumes that one party is largely uninterested in reforms that go beyond tweaking the status quo and opposing whatever further interventions its opponents have in mind.

And it’s a dynamic that in the long run puts Republicans — and everyone who supports more market-driven health care — at a disadvantage relative to their more engaged Democratic opponents: It is, after all, the same dynamic that gave us Obamacare in the first place.